http://www.ijwhr.net doi 10.15296/ijwhr.2014.

53

Open Access Case Report

International Journal of Women’s Health and Reproduction Sciences
Vol. 2, No. 5, Autumn 2014, 320–322
ISSN 2330- 4456

Prenatal Diagnosis of Placenta Percreta with Ultrasound

Burcu Artunc Ulkumen1*, Halil Gursoy Pala2, Yesim Baytur3

Abstract
The incidence of the placental invasion anomalies are increasing, mainly due to repeat cesarean deliveries. Placenta percreta occurs if
these villi perforate the serosa and also sometimes into adjacent organs such as the bladder. The prenatal diagnosis is very important
because of the high maternal morbidity and mortality rates without the appropriate surgical planning. The adherent placentas
will result in severe early postpartum bleeding, just after the delivery of the fetus. Severe hemorrhage usually results rapidly in
disseminated intravascular coagulation (DIC), shock, multiorgan failure or death.The surgery is also challenging due to the risk of
the adjacent tissue damage, such as bladder or ureteral injury. Approximately 1 in every 3 cases need intensive care. We present here
a prenatally diagnosed, 31-year-old gravida 7 para 2 abortus 4 pregnant case with placenta percreta and rewiev the relevant literature
about the key aspects in the ultrasonograhic diagnosis and underlie the key points in the diagnosis.
Keywords: Placental Invasion Anomaly, Placenta Percreta, Obstetric Ultrasound

Introduction deliveries. She never had vaginal bleeding during her

Placental invasion anomalies refer to the abnormal
adherence of the placenta to the uterine wall resulting
in subsequent detachment failure after the delivery (1).
According to the depth of the invasion, there are three
sub-groups: placenta accreta occurs if the villi penetrate
the decidua but not the myometrium; placenta increta
occurs if the villi penetrate through the myometrium;
placenta percreta occurs if these villi perforate the serosa
and also sometimes into adjacent organs such as the
bladder (2). The prevalence is approximately 1 in 2500
pregnancies. However, placenta previa rises the risk
more than 10 fold (3). The most frequent predisposing
factors are prior cesarean operations and placenta previa.
The provenance is rising due to the increase in cesarean
operations worldwide (4).
The adherent placentas will result in severe early
postpartum bleeding, just after the delivery of the fetus.
Severe hemorrhage usually results rapidly in disseminated
intravascular coagulation (DIC), shock, multiorgan
failure or death. The surgery is also challenging due to
the risk of adjacent tissue damage such as ureteral injury
(2%) and bladder injury (15%). Approximately 1 in every
3 case need intensive care (5). The associated maternal
morbidity and mortality risk emphasizes the importance
of the prenatal diagnosis. We present here a prenatally
diagnosed case of placenta percreta with the emphasis on
the importance of the prenatal diagnosis and underlie the
key points in the diagnosis.
Case Presentation
A 31-year-old gravida 7 para 2 abortus 4 pregnant
woman was referred at her 32 gestational weeks to our
perinatology outpatient clinic due to two prior cesarean
pregnancy. Abdominal ultrasound revealed a 32-week
fetus with positive cardiac activity. Amniotic fluid was
normal. The placenta was lying through the anterior
uterine wall with partial closure of the internal cervical os
(Figure 1). Due to prior cesarean deliveries and placenta
previa partialis with anterior localisation, a targeted
ultrasound examination was made and revealed that the
retroplacental myometrial zone was non-visible; lacunae
could be seen in the lower uterine segment (Figure-1);
rich venous blood flow in these intraplacental lacunae was
established via color Doppler, the zone between bladder
and retroplacental area was irregular (Figure-2). Placenta
percreta was our prediagnosis. We scheduled her cesarean
operation at 36th gestational week. A pfannenstiel incision
was performed. Intraoperative observation of the uterus
revealed placenta percreta; but there was no bladder
involvement (Figure 3). A longitudinal fundal incision
dextrally was made to avoid the placenta (as the placenta
was lying through the anterior wall toward the left side),
and a 2200 gr female healthy baby was delivered. The
umbilical cord was clamped and the placenta was left in the
uterus. Hysterectomy was performed without extracting
the placenta. Five units of erythrocyte suspensions and
4 units of fresh frozen plasma were given preoperatively.
The patient was followed-up in intensive care unit for the
first day postoperatively. The postoperative period was
uneventful. The patient was discharged at the 7th day
postoperatively. The pathological examination revealed
placenta percreta.
Discussion
The histological changes within the myometrial spiral
arterioles which take place as a result of the natural process

Received 7 March 2014, Revised 21 March 2014, Accepted 2 April 2014, Available online 20 July 2014
1
Assistant Professor, Celal Bayar University School of Medicine, Obstetrics and Gynecology Department, Manisa, Turkey. 2Specialist MD, Celal
Bayar University School of Medicine, Obstetrics and Gynecology Department, Manisa, Turkey. 3Professor, Celal Bayar University School of
Medicine, Obstetrics and Gynecology Department, Manisa, Turkey.
*Corresponding Author: Burcu Artunc Ulkumen, Assistant Professor; Celal Bayar University School of Medicine, Obstetrics and Gynecology
Department, Manisa, Turkey. Tel: +905324144162, Email: artunc.burcu@gmail.com
Ulkumen et al.
Figure 1. The gray-scale sonographic image of the adherent
placenta: the intraplacental lacunae (purple arrow), the irregular
border between the placenta and bladder (red arrow), loss of ret-
roplacental clear space (yellow arrow).
Figure 2. The main diagnostic clues on the color Doppler image
of the adherent placenta: loss of retroplacental clear space (yel-
low arrow), gap in the retroplacental blood flow (red arrow), rich
blood flow in placental lacunae (purple arrow).
Figure 3. Placenta percreta: postoperative view.
of the pregnancy are different in adherent placentas. The
endometrium during pregnancy is defined as the decidua.
Decidua basalis (also called decidua placentalis) is the part
where the trophoblasts meet the decidual lining. Placental
invasion anomalies take place if there is improper
development of the Nitabuch’s layer with the absence of
the decidua basalis. The histological changes in vascular
structures like spiral arterioles develop in the deeper layer
International Journal of Women’s Health and Reproduction Sciences, Vol. 2, No. 5, Autumn 2014
of the myometrium (2).
The etiology is not well-known. However; multiparity,
prior cesarean deliveries, prior abortus history,
maternal smoking, prior myomectomy and uterine
anomalies are associated with increased risk (6). Prior
curettage interventions may affect the endometrial local
environment by scar tissue formation and sclerotic changes
leading to subsequent defective placentation (6,7). In our
case, prior 4 abortion histories and 2 cesarean deliveries
were risk factors. Besides, our case was a smoker. Smoking
status has been defined as a high risk factor. In a meta-
analysis, Faiz et al. proposed that one in four cases would
be preventable by quitting smoking (8).
Prenatal diagnosis is important in order to plan the
surgical intervention timely. The surgeon has to get the
blood products ready, to arrange the anesthesia team for
the proper surgery preparation, to inform the patient
correctly about the surgical risks, adjacent tissue damage
and the need of hysterectomy. Cesarean is planned during
36th gestational week in order to avoid spontaneous
severe bleeding and spontaneous labor. Uterine incision
is performed vertically in order to avoid the placenta
preventing excessive blood loss. If hysterectomy is needed,
placenta should be left in the uterus and the next surgical
steps should be initiated.
Ultrasonography is the main tool in diagnosis. It detects
up to 80% of the cases (9). During the 18-23 week detailed
sonographic examination, the risk factors should be
evaluated for each pregnant woman. Regarding high-
risk pregnancies with prior cesarean operations, prior
curettage history or current placenta previa; a targeted
sonographic examination would be reasonable to detect
placental invasion anomalies (10).
In 1980’s, Tabsh et al. and Mondenca et al. were the first
describing some typical sonographic profiles of placenta
accreta (11,12). They identified that the natural peripheric
hypoechoic zone between placenta and myometrium
could not be visualized in adherent placentas. Hoffman-
Tretin and co-workers described some additional features:
multiple intra-placental lakes and progressive thinning
of the retroplacental hypoechoic myometrial zone on
each subsequent visit (13). Finberg et al. identified two
additional sonographic profiles for placenta percreta
cases: a thinning or focal disruption area of the uterine
serosa-bladder wall complex and the appearance of a
focal mass beyond the uterine serosa, with the same
echogenicity of placenta (14). Lerner and co-workers (15)
were the first who tried to diagnose the adherent placenta
antenatally by color doppler and transvaginal sonography.
Chou et al. showed dense and highly pulsatile blood
flow within placental lacunae (16). MRI can be helpful
in posteriorly located adherent placentas and in unclear
sonographic profiles (10).
In our perinatology outpatient clinic, we perform a
targeted ultrasound examination for low uterine segment
for high-risk pregnancies during the detailed screening
between 18-23 gestational weeks. We evaluate firstly
the placental localisation. We remark the intraplacental
321
Ulkumen et al.
anechoic areas: lacunae are vascular structures with
different size and shapes especially prominent in the third
trimester having turbulent flow within. Placental lakes
are round shaped anechoic areas with laminar blood flow
in it and with uneventful outcomes (10). We carefully
evaluate the normal clear zone between placenta and
myometrium. Loss of this zone may indicate the adherent
placenta. After that, we evaluate the suspected zone also
with color doppler: any gap in the myometrial blood flow
in the retroplacental area may be alarming about the
adherent placenta. In order to evaluate the region between
the bladder and uterine serosa, the bladder needs to be
full. We prefer transabdominal sonographic examination
during the daily practice. However, Lerner et al suggested
that transvaginal sonography may enhance the accurate
antenatal diagnosis of the adherent placentas. Transvaginal
sonography has better near-field resolution power for the
evaluation of the region between the placenta and lower
uterine segment (15). We prefer transvaginal sonography
if we could not evaluate the lower uterine segment
properly (especially in obese women with prior cesarean)
or if the placenta has posterior location.
Recent studies showed that visualization of placental
lacunae had the highest sensitivity (93%) for the detection
of placenta accreta between 15-40 gestational weeks.
In contrast to placental lakes with rounded and smooth
bordered shapes, lacunae tend to be more linear with
irregular borders. Placenta with lacunae has typical
‘moth-eaten’ appearance (17). Similarly, we found on
2-dimensional gray-scale sonographic examination
irregular placental lacunae with rough borders. On color
doppler, there was turbulent flow in these lacunae. We
also found bulging and interruption of the integrity
between the bladder and uterine wall which may also
warned us about the adherent placenta; however, also a
prior cesarean operation with the retraction of the bladder
peritoneum before the uterine incision could have resulted
in the increase of the vascularity in that area which may
have caused an impression of placenta percreta.
Conclusion
As a result, the turbulent blood flow in placental lacunae
especially in the third trimester, loss of retroplacental
anechoic regular zone, rich and irregular blood flow into
the adjacent tissues from the placenta should warn the
clinician about the risk of the adherent placenta. In case of
unclear diagnosis, MRI may be helpful.
Ethical issues
The local ethics committee approved the study.
Conflict of interests
None.
Copyright © 2014 The Author(s); This is an open-access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
322 International Journal of Women’s Health and Reproduction Sciences, Vol. 2, No. 5, Autumn 2014
References
1. Kent A. Management of placenta accreta. Rev Obstet
Gynecol 2009; 2(2): 127- 8.
2. Callen PW. Ultrasound evaluation of the placenta
and umbilical cord. In: Feldstein VA, et al (ed).
Ultrasonography in obstetrics and gynecology. 5th
edition Saunders,Elsevier;2008. p. 737-39.
3. Morgan K, Arulkumaran S. Antepartum haemorrhage.
Curr Obstet Gynecol 2003; 13: 81-87.
4. Yeniel AÖ, Ergenoglu M, Zeybek B, Karadadas N.
Placenta previa percreta. Ege Journal of Medicine 2010;
49(2):123-127.
5. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong
CY, Thom EA, et al. Maternal morbidity associated with
multiple repeat cesarean deliveries. Obstet Gynecol 2006;
107:1226–1232.
6. Tuzovic L, Djelmis J, Ilıjıc M. Obstetric Risk Factors
Associated with Placenta Previa Development: Case-
Control Study. CMJ 2003; 44(6):728-733.
7. Sheiner E, Shoham-Vardi I, Hallak M, Hershkowitz R,
Katz M, Mazor M. Placenta previa: obstetric risk factors
and pregnancy outcome. J Matern Fetal Med 2001;
10:414-9.
8. Faiz AS, Ananth CV. Etiology and risk factors for placenta
previa: an overview and meta- analysis of observational
studies. J Matern Fetal Neonatal Med 2003; 13:175- 190.
9. Warshak CR, Eskander R, Hull AD, Scioscia AL, Mattrey
RF, Benirschke K, et al. Accuracy of ultrasonography and
magnetic resonance imaging in the diagnosis of placenta
accreta. Obstet Gynecol 2006; 108:573–581.
10. Baughman WC, Corteville JE, Shah RR. Placenta Accreta:
Spectrum of US and MR Imaging Findings. Radio
Graphics 2008; 28(7):1905-16.
11. Tabsh KMA, Brinkman CR, King W. Ultrasound diagnosis
of placenta increata. J Clin Ultrasound 1982; 10:288.
12. Mendonca LK. Sonographic diagnosis of placenta
accreata, presentation of six cases. J Ultrasound Med
1988; 7: 211-15.
13. Hoffman-Tretin JC, Koenigsberg M, Rabin A,
Anyaegbunam A. Placenta accreta: additional sonographic
observations. J Ultrasound Med 1992; 11:29-34.
14. Finberg HJ, Williams JW. Placenta accreata: prospective
sonographic diagnosis in patients with placenta previa
and prior cesarean section. J Ultrasoun Med 1992;
11:333-43.
15. Lerner JP, Deane S, Timor-Tritsch IE. Characterization
of placenta accreata using transvaginal sonography and
color doppler imaging. Ultrasound Obstet Gynecol 1995;
5:198-201.
16. Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta
previa/accreta with color doppler ultrasound. Ultrasound
Obstet Gynecol. 2000;15(1):28-35.
17. Comstock CH. Antenatal diagnosis of placenta accreta: a
review. Ultrasound Obstet Gynecol 2005; 26:89-96.